Common terms and conditions that insurance carriers use to deny benefits.

December 19, 2018

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Posted By: Russell Schafer, DDS

In the previous two blog posts, I’ve discussed various dental insurance terms that carriers use to help you better understand dental benefits. Probably though, the most frustrating thing that most patients and dentists experience with carriers is denials of benefits. Unfortunately, dental insurance companies lose money each time they pay out a claim and some of them have departments and systems set up to deny coverage to their subscribers. In this short essay, I’d like to describe common terms and conditions that insurance carriers use to deny benefits to ensure that they don’t pay out too much money for your care as well as what you can do to ensure you get the benefits that you deserve and for which you’ve already paid. I will discuss frequency limits, missing tooth clause, down-coding, and denials as well as steps that you can take to get these covered.

Frequency Limit or Missing Tooth Clauses

The two most common reasons for a service not being covered is either because the frequency limit has been met or the plan has a missing tooth clause. Common frequency limits for preventive treatment that most insurance companies allow are two regular cleanings in a given year, three exams in a year, and set of routine x-rays once a year. Other common limits are a crown on a tooth every 5 years and a filling every 2 years. If you go past this limit, typically the insurance will not cover for the procedure. For example, we had a patient who had a crown done on a front tooth three years ago. His toddler headbutted him and chipped the tooth. The insurance denied redoing the crown as it was below the frequency limit. While most people can understand the frequency limits, the missing tooth clause is much more insidious. Simply stated, the insurance company says that if you started a plan missing a given tooth, it will not pay to have the tooth replaced. For example, if you get a tooth removed while on an insurance and a few years later you switch insurance plans, the new plan will not cover that tooth. Even if this tooth has been replaced with either an implant, bridge, or partial, the carrier will still deny the benefit. This is a textbook case of a pre-existing condition and can severely limit the care for which you can have paid. This is the worst for patients with no teeth in their mouth and have a full set of dentures as generally the insurance will only cover exam and x-rays and the typical x-rays for denture patients are taken every 3 years.

Down-Coding & Denials

The next common way that insurances don’t pay for your care are through down-coding and denials. Down-coding is a process where the insurance company gives an “alternative benefit” for the service. For example, the insurance might only cover the cost of a removable partial denture when a patient elects to have a tooth replaced by an implant. This means that the insurance company is only on the hook for around 300 dollars rather than 800 to 1200 dollars. The most common way this applies is that most insurances only cover silver fillings on back teeth. White fillings usually cost more, but the insurance will only cover whatever they would have covered for a silver filling after the procedure is done. The last thing that insurance companies will do is straight out deny a claim. Either they will say that the procedure was not needed or that it is not a covered benefit. This can even happen if there is a pre-authorization on file for the procedure to be done. Some insurance companies will do this for every major procedure, and the reason is that they know that if they deny every one of them that a handful of the patients and dentists will not fight the denial. For example, some companies will not ever approve a crown the first time it is submitted to them. Our insurance specialist knows this in advance and we are generally ready to just resubmit the claim.

What You Can Do

While this might seem hopeless, there are easy things that you the subscriber can do to help ensure you get coverage. The most important thing that you can do is to call your insurance company and demand to know why they are not covering a procedure. Generally, the insurance companies will be nicer to the subscriber than the are to the dental office as the subscriber is their customer. While it might take a bit of your time to be on the phone with them, we have found this to be the most effective way to resolve any dispute. The second way is to talk with your company’s HR department. HR departments are the ones who hire dental carriers to administer their dental policy and they hire dental carriers to keep their employees happy. If you are not satisfied with your dental carrier, talk with your HR department and that can be an effective way of getting change.

I hope that this three-part blog series on dental insurance has been useful. Unfortunately, dental carriers don’t make money when they pay for your care and will do a lot to keep you from paying for your claims. If you need help with your dental policy and making sure that it is fully utilized, please call us today and we will do our best to help you.

During this Covid-19 pandemic, Dr. Schafer and his team are remaining open for dental emergencies per CDC and ADA guidelines but are postponing all other treatment until the health authorities give clearance. Dental emergencies included painful or sensitive teeth or anything that seems like it is worsening. If you are having a dental emergency, call us today and we will help you out.